Sexual and reproductive health among forcibly displaced persons in urban environments in low and middle-income countries: scoping review findings

Background Most forcibly displaced persons are hosted in low- and middle-income countries (LMIC). There is a growing urbanization of forcibly displaced persons, whereby most refugees and nearly half of internally displaced persons live in urban areas. This scoping review assesses the sexual and reproductive health (SRH) needs, outcomes, and priorities among forcibly displaced persons living in urban LMIC. Methods Following The Joanna Briggs Institute scoping review methodology we searched eight databases for literature published between 1998 and 2023 on SRH needs among urban refugees in LMIC. SHR was operationalized as any dimension of sexual health (comprehensive sexuality education [CSE]; sexual and gender based violence [GBV]; HIV and STI prevention and control; sexual function and psychosexual counseling) and/or reproductive health (antental, intrapartum, and postnatal care; contraception; fertility care; safe abortion care). Searches included peer-reviewed and grey literature studies across quantitative, qualitative, or mixed-methods designs. Findings The review included 92 studies spanning 100 countries: 55 peer-reviewed publications and 37 grey literature reports. Most peer-reviewed articles (n = 38) discussed sexual health domains including: GBV (n = 23); HIV/STI (n = 19); and CSE (n = 12). Over one-third (n = 20) discussed reproductive health, including: antenatal, intrapartum and postnatal care (n = 13); contraception (n = 13); fertility (n = 1); and safe abortion (n = 1). Eight included both reproductive and sexual health. Most grey literature (n = 29) examined GBV vulnerabilities. Themes across studies revealed social-ecological barriers to realizing optimal SRH and accessing SRH services, including factors spanning structural (e.g., livelihood loss), health institution (e.g., lack of health insurance), community (e.g., reduced social support), interpersonal (e.g., gender inequitable relationships), and intrapersonal (e.g., low literacy) levels. Conclusions This review identified displacement processes, resource insecurities, and multiple forms of stigma as factors contributing to poor SRH outcomes, as well as producing SRH access barriers for forcibly displaced individuals in urban LMIC. Findings have implications for mobilizing innovative approaches such as self-care strategies for SRH (e.g., HIV self-testing) to address these gaps. Regions such as Africa, Latin America, and the Caribbean are underrepresented in research in this review. Our findings can guide SRH providers, policymakers, and researchers to develop programming to address the diverse SRH needs of urban forcibly displaced persons in LMIC. Plain English summary Most forcibly displaced individuals live in low- and middle-income countries (LMICs), with a significant number residing in urban areas. This scoping review examines the sexual and reproductive health (SRH) outcomes of forcibly displaced individuals in urban LMICs. We searched eight databases for relevant literature published between 1998 and 2023. Inclusion criteria encompassed peer-reviewed articles and grey literature. SRH was defined to include various dimensions of sexual health (comprehensive sexuality education; sexual and gender-based violence; HIV/ STI prevention; sexual function, and psychosexual counseling) and reproductive health (antenatal, intrapartum, and postnatal care; contraception; fertility care; and safe abortion care). We included 90 documents (53 peer-reviewed articles, 37 grey literature reports) spanning 100 countries. Most peer-reviewed articles addressed sexual health and approximately one-third centered reproductive health. The grey literature primarily explored sexual and gender-based violence vulnerabilities. Identified SRH barriers encompassed challenges across structural (livelihood loss), health institution (lack of insurance), community (reduced social support), interpersonal (gender inequities), and individual (low literacy) levels. Findings underscore gaps in addressing SRH needs among urban refugees in LMICs specifically regarding sexual function, fertility care, and safe abortion, as well as regional knowledge gaps regarding urban refugees in Africa, Latin America, and the Caribbean. Self-care strategies for SRH (e.g., HIV self-testing, long-acting self-injectable contraception, abortion self-management) hold significant promise to address SRH barriers experienced by urban refugees and warrant further exploration with this population. Urgent research efforts are necessary to bridge these knowledge gaps and develop tailored interventions aimed at supporting urban refugees in LMICs. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-024-01780-7.


Background
As of mid-2022, the global number of forcibly displaced individuals reached an estimate of 103 million [1], a significant majority of this population (53.2 million individuals) are internally displaced [1].While approximately one-third, totaling 32.5 million people, hold recognized refugee status, another 4.9 million individuals are actively seeking asylum in another country [1,2].Forcibly displaced persons may experience poorer sexual and reproductive (SRH) outcomes than non-displaced persons due to the interplay of complex social ecological factors [3].For instance, forcibly displaced persons may be exposed to sexual and gender-based violence (GBV) before, during, and/or following displacement, and/or upon resettlement.Further, they may experience reduced access to SRH services, including contraception and sexually transmitted infection (STI) prevention and treatment, due to poverty, socio-cultural differences, language, and literacy barriers [4][5][6][7].Social and structural barriers such as intersectional stigma related to forcibly displaced status, gender, age, and limited SRH literacy can further constrain SRH engagement [8,9].
Low-and middle-income countries (LMIC) host 74% of the globally forcibly displaced population, and it is estimated that the majority of refugees and nearly half (48%) of internally displaced people live in urban areas [1, 2,10].There is the potential that forcibly displaced persons residing in urban settings LMIC may live in poorer housing conditions with less economic and social support than those living in refugee camps or refugee settlement environments managed by humanitarian agencies [11,12].For instance, challenges facing forcibly displaced persons living in urban LMIC contexts can include transportation costs, higher living costs that may result in overcrowded living conditions, poverty, and language barriers to accessing relevant employment, education, health and other services [13][14][15].It is plausible that these factors can also reduce the accessibility and utilization of SRH services.Inadequate SRH service provision is associated with increased gender-based violence (GBV), elevated risks for acquisition and transmission of HIV and other STIs, unintended pregnancies, and unsafe abortions [8,16].Further, urbanization among refugees may contribute to poverty and exacerbate gender inequities, both associated with increased likelihood of GBV [3,17,18].With rising urbanization among forcibly displaced persons, there is a need for greater understanding of the sexual and reproductive health (SRH) outcomes and priorities to inform tailored intervention and programs.
Existing systematic reviews have reported evidencebased approaches to improve antenatal, postnatal, and newborn health, HIV prevention and treatment outcomes, and uptake of family planning resources and services, for forcibly displaced persons at large [19,20].There is evidence that interpersonal, health-system, and socio-cultural factors shape access to SRH care among forcibly displaced peoples [21].Literature has also documented relationships between climate migration and GBV, decreased maternal and neonatal health, and increased barriers to accessing and using SRH services [22].While these important reviews document factors that shape SRH among forcibly displaced peoples at large, there remains a notable lack of research focused on forcibly displaced persons regarding SRH issues including GBV prevention, STI transmission and treatment, menstruation hygiene management, and disrupted access to SRH care [19,22].Further, findings have not distinguished between urban or refugee camp/settlement contexts, resulting in a lack of clarity regarding specific needs, priorites, and SRH outcomes among forcibly displaced persons in urban LMIC contexts.
The objective of this scoping review is to identify, critically appraise, and synthesize the literature on sexual and reproductive health needs, outcomes, and priorities of forcibly displaced persons living in urban LMICs.A comprehensive understanding of these dimensions and existing research gaps can inform future practice, research, and policy.

Methods
The Joanna Briggs Institute methodology for scoping reviews was followed throughout this review [23].A complete and comprehensive explanation of the methods used can be found in the published study protocol [24].

Search strategy
Completed in January 2023, we searched eight databases, MEDLINE, EMBASE, PsycINFO, CINAHL, IBSS, ASSIA, SSCI, and Global Medicus Index, for literature published between 1998 and 2022 on SRH needs among forcibly displaced persons in LMIC.The search structure first grouped terms for each of urban, refugees, sexual health, low and middle-income countries, and reproductive health using the Boolean operator OR.Following this, terms for urban and refugees were combined using the Boolean operator AND, and terms for sexual health and reproductive health were combined using the Boolean operator OR.Lastly, the search terms for urban refugees, sexual health or reproductive health, and low and middle-income countries were combined using the Boolean operator AND -((urban OR cities OR municipal) AND (refugee* OR displace* OR asylum)) AND ((sexual health OR gender-based violence OR sexually transmitted disease*) OR (reproductive health OR prenatal OR contraception)) AND (low income countries OR middle income countries OR developing nations).A detailed search strategy for all databases can be found in the Supplementary File 1.A grey literature search was also conducted in accordance with a search guide developed by Godin et al. [25].

Study selection
The study population was a) any forcibly displaced person, following UNHCR's definition that includes refugee, migrant, asylum seeker, or internally displaced persons forced to flee due to persecution, conflict, human rights violations, or other serious events disrupting order [1, 2], b) living in a LMIC as defined by the World Bank Atlas Method [26] and c) living in an urban context, including urban, semi-urban, city, metropolis, or if study location is listed as urban in the UN World Urbanization Prospects database of country-specific definitions of 'urban' [27].SRH was operationalized as any dimension of sexual health (comprehensive sexuality education [CSE]; sexual and gender based violence [GBV]; HIV and STI prevention and control; sexual function and psychosexual counseling) and/or reproductive health (antental, intrapartum, and postnatal care; contraception counselling and provision; fertility care; safe abortion care) [28,29].
We included peer-reviewed or gray literature studies using quantitative, qualitative, or mixed-methods designs focused on any dimension of sexual/reproductive health written in the English language.Studies were excluded if they a) did not include forcibly displaced persons; b) included migrants by choice; c) did not focus on SRH; d) were not based in urban contexts; e) had metadata not in English; and f ) there was no full-text article available.Key subject terms were searched among websites of governmental, non-governmental, and international organizations working with forcibly displaced persons.

Data extraction and analysis
Once both the database search and grey literature search were completed, data from included records were extracted by a reviewer into a spreadsheet.All records were uploaded on to Covidence systematic review software (VeritasHealth Innovation, Melbourne, Australia) and duplicates were removed.On Covidence, each record's title and abstract were screened by at least 2 study team members for inclusion eligibility.The full texts of all included articles were further screened by two study team members.At this point, the reference list of each included article was manually hand searched.If a relevant article was found via hand search, it was entered into Covidence and put through the screening process as outlined.All discrepancies were reviewed by a third team member and/or discussed with all reviewers.Extracted data points included the record's general characteristics, population, concept, context, main outcome measure, and key findings relevant to this review.Every record's data extraction was examined by a second team member for accuracy.All data were then summarized and collated into the accompanying narrative summaries.

Results
Our peer-reviewed article search returned 1151 results across eight databases and 2275 grey literature reports.In total, 92 documents including 55 peer-reviewed articles and 37 grey literature pieces met the inclusion criteria for this scoping review.Among the peerreviewed articles, PRISMA Flow Chart in Fig. 1 shows the selection process for 53 peer-reveiewed articles (Fig. 1).Six additional peer-reviewed articles were hand searched, 2 of which met the inclusion criteria and were included.
The peer-reviewed articles were mapped onto dimensions of sexual health and reproductive health [29] (Table 1).The majority of peer-reviewed articles (n = 40; 72.7%) discussed sexual health domains including: GBV prevention, support and care (n = 23); HIV and STI prevention and control (n = 21); and comprehensive sexuality education (n = 12).Under the sexual health domain, no articles were located that discussed sexual function and psychosexual counselling.More than one-third (n = 20; 36.3%)discussed reproductive health areas including: antenatal, intrapartum and postnatal care (n = 13); contraception counselling & provision (n = 13); fertility care (n = 1); and safe abortion care (n = 1).While not within the SRH framework [28,29], menstrual hygiene management was included as a SRH issue in this review as it was discussed in three articles.Eight articles discussed intervention areas that included both reproductive and sexual health domains.Sexual and reproductive health dimensions covered in peer-reviewed articles are displayed in Table 2.

Prevalence and health correlates of intimate partner violence
Of the 17 articles that examined GBV, most (n = 11; 64.7%) specifically examined intimate partner violence (IPV) [32, 33, 40-42, 45, 52, 61, 69, 73, 76].Prevalence ranged from 11.1%-86.0%and varied by age, type of IPV, and external factors.All studies examined the experience of adults, with the exception of two that looked at adolescents, and these found the highest prevalences of IPV at 85.8% and 86.0%[52,76].Two articles examined the prevalence of different types of IPV.One study found partner control followed by economic abuse and emotional abuse to be the most common forms of IPV at 73%, 53.3%, and 50.3% respectively [33].Another study found slapping and throwing objects to be the most common forms of physical IPV [41].
More than half of these articles reported associations between IPV and health and wellbeing (n = 6), incuding mental, physical, and other SRH outcomes.For instance, there were associations between experiencing IPV and mental health concerns such as post-traumatic stress disorder symptoms [61] and frequent alcohol use [52].One study with refugee women in Amman, Irbid and Zarqa, Jordan found an association between psychological IPV and higher rates of health problems including heart, gastrointestinal, liver, respiratory, and urinary problems, recurrent dizziness, fibromyalgia, joint pain, and back pain [32].Another study with refugee women in Semnan, Iran found IPV exposure was associated with a range of SRH outcomes, including early marriage, sexual coercion, unwanted pregnancy, and a high number of children [40].
The different ways that IPV was measured across studies make it difficult to synthesize these findings, however across studies it appears that a) urban forcibly displaced girls and women are disproportionately exposed to

Table 2
Summary of sexual and reproductive health dimensions examined in included peer-reviewed articles in scoping review of sexual and reproductive health among urban forcibly displaced persons in low and middleincome countries [13,17,18,[30][31][32][33][34][35][36][37] Table 2 (continued) R refugees, D displaced persons, ID internally displaced persons, FD forcibly displaced persons, M migrants, HW humanitarian workers, HP healthcare providers, HC host community members, CL community leaders, AS asylum seekers, AW adult women, AM adult men, PAW pregnant adult women, FA female adolescents, MAL male adolescents, FY female youth, MY male youth polvictimization (multiple forms of violence); b) there is a range of health challenges linked with IPV exposure, including and extending beyond SRH; and c) married women reported a high prevalence of IPV, including during pregnancy.

Risk factors associated with GBV exposure
Seven of the 17 articles that examined GBV explored risks associated with GBV exposure (41.2%) [36,37,42,46,52,68,75].Three studies collected data from women only [36,42,46] while the other four collected data from both women and men [37,52,68,75].One study found that women were more likely to share stories about sexual harassment while men more likely to discuss other forms of GBV [68].
GBV exposure risks varied across social categories, including age, education, changing social structures and norms, and disruption to social networks and livelihoods.For instance, studies with adolescent girls and young women, including refugees in Beirut, Beqaa, and Tripoli, Lebanon [68] and displaced people in Izmir, Turkey [75], reported that early marriage was associated with risks for further GBV [68,75].Among those experiencing early marriage, factors that increased risks for GBV included limited educational opportunities, financial strains, and being alone outside the home [75].Further, urbanization may change parents' perspectives on child marriage after arriving in Lebanon, as they may be more likely to view early marriage as a pathway to protecting their daughters and reducing parental responsibility [39].
Among internally displaced adult women, displacement and subsequent loss of social support networks elevated risks for GBV [36,37].For instance, in a study conducted in Port-au-Prince, Haiti, destruction of livelihood elevated risks for GBV [36].Findings paralleled another study in Abidjan, Côte d'Ivoire that documented that poverty, food and housing instability, and changing gender roles and norms increased GBV exposure [37].Partner characteristics and relationship dynamics were also associated with GBV, including partner alcohol misuse [41,42].Among pregnant refugees in Sidon, Lebanon, odds of IPV were higher among those whose husbands did not want the pregnancy [42].
Polyvictimization was also reported [73,74,76].For instance, forcibly displaced women with a history of childhood abuse may be more likely to experience adulthood violence [76], and as adult, forcibly displaced women may report multiple forms (e.g., physical violence, abductions, forced imprisonment, sexual violence, early/forced marriage) and contexts of violence (country of origin, host country) [74].Together these studies on GBV suggest that multi-level factors, including structural (poverty, livelihood and educational barriers), social (gender inequitable norms, disrupted social networks), and relational (relationship power dynamics, partner alcohol use) level factors increase vulnerability to multiple forms of GBV among urban forcibly displaced persons.

HIV and other sexually transmitted infections (STIs)
Among the 20 articles examining HIV and STIs, 17 focused only on HIV, one article focused on HIV and transactional sex [50], one on STIs [49], and one on both HIV and STIs [54].
Among articles that examined HIV testing [13,44,47,51,53,56], transportation costs, overcrowded living conditions, low literacy, and inequitable gender norms were identified as testing barriers [13,53].Intersecting stigma-including stigma related to HIV, refugees, sexually active adolescents, and sex workers-also presented barriers to HIV testing among urban refugee youth in Kampala, Uganda [44,47,51].Among urban Venezuelan forcibly displaced women in 6 cities in Peru (Metropolitan Lima, Callao, Tumbes, Cusco, Trujillo, Arequipa), not having health insurance was a barrier to HIV and STI testing [56].Among MSM in Beirut, Lebanon, lack of comfort with doctors, not seeing a doctor in the past year, and not knowing where to access testing posed as barriers to testing [70,71] Among forcibly displaced urban refugee youth in Kampala, Uganda, factors associated with STI testing were lower food insecurity and lower adolescent SRH stigma [49].
Several studies focused on HIV vulnerabilities among forcibly displaced persons in urban Uganda [52,66,78].For instance, a study in Gulu with internally displaced men and women reported an HIV prevalence of 12.8%, and risk factors associated with HIV infection included non-consensual sexual debut, past-year STI symptoms, and practicing dry sex (which was defined as sexual intercourse without foreplay or lubrication so that the vagina is dry upon penetration) [66].Another study in Kampala, Uganda with refugee youth found that depression, alcohol use, and GBV were associated with HIV vulnerabilities, including recent transactional sex and multiple sex partners [52].There may also be gender differences in HIV vulnerabilities; among urban refugee adolescents in Kampala, Uganda, young men reported higher condom self-efficacy than young women [62,63].A study in Beirut, Lebanon found that over half (56.7%) of refugee MSM reported unprotected anal intercourse with men who were HIV positive or did not know their HIV serostatus, and over a third (36%) had engaged in transactional sex [70,71].A qualitative study with internally displaced women in Northern Uganda found that the shift away from traditional belief systems, collapse of livelihoods, commuting away from home at night, and inadequate access to SRH information and services elevated HIV vulnerabilities among adolescent girls [78].Another qualitative study, with forcibly displaced adult women in Medellin, Colombia, found that social and family fragmentation, GBV, abrupt changes in daily lives, and inequitable gender norms elevated HIV and STI acquisition risks [54].These studies taken together reveal the ways that conflict-related life disruptions (e.g., belief systems, livelihoods, social networks), alongside structural factors (e.g., gender inequities, SGBV across the lifecourse, barriers to accessing SRH services) and relational factors (e.g., sexual practices, low condom efficacy), may increase exposure to HIV and STIs and reduce access to testing.

HIV treatment and care
Four articles focused on antiretroviral therapy (ART) and HIV care among urban refugee adult men and women [58][59][60]64].Two quantitative studies in Kuala Lumpur, Malaysia that compared HIV treatment and clinical outcomes between refugees, displaced people, asylum seekers, and host community members found no differences in viral suppression among groups [58,59].Qualitative studies explored challenges associated with achieving optimal treatment adherence [60,64].One of these studies that included forcibly displaced persons in Kuala Lumpur, Malaysia found that limited access to food, pharmacy stock-outs, and difficulty navigating a new health system were barriers to optimal treatment adherence [60].The few studies on HIV treatment and care that were included in this review span wide-ranging contexts, presenting challenges in drawing conclusions from this evidence-base and signal the need for more research with urban forcibly displaced persons living with HIV.

Antenatal care, postnatal care, and contraception
Among the 13 articles that explored antenatal and postnatal care and contraception, six focused on antenatal and postnatal care (46.2%) [30,34,35,38,65,72] and seven on contraception and family planning (53.8%) [31,43,55,56,62,63,67].Most of these studies were conducted with adult forcibly displaced women (n = 9); one was conducted with healthcare workers and policy makers alongside adult women [34].The remaining three studies were conducted with forcibly displaced adolescents, one of which explored experiences of only women [55].

Antenatal and postnatal care
Two of the 13 articles that examined antenatal and postnatal care used quantitative methods to explore uptake of antenatal care [30,35].One study found that 82.9% of pregnant refugees had received some antenatal care in 14 high refugee density sites, including Beirut, in Lebanon [35], while another study found that pregnant refugees in Tehran, Iran attended an average of 3.73 out of 8 possible antenatal appointments [30].Four articles explored barriers to accessing care and related risks [34,38,65,72].One of these studies with pregnant refugees in South Tehran, Iran found that financial constraints, lack of health insurance, transportation challenges, stigma, cultural concerns, legal and immigration issues, and healthcare staff behaviour presented barriers to utilizing prenatal services [38].Moreover, an article with pregnant forced migrant mothers in Mumbai, India reported that they could not access the antenatal care they need due to unfamiliarity with the local context and a lack of knowledge regarding where to access antenatal care, putting them at a greater risk for poor health outcomes [65].From these limited studies, structural level challenges (e.g., health insurance barriers, healthcare mistreatment, immigration issues) alongside socio-cultural challenges (e.g., stigma, cultural and religious concerns) posed barriers to antenatal and postnatal care.

Contraception
Among the seven articles that explored family planning, five used quantitative methods to explore the access and utilization of contraceptives [55,56,62,63,67].One study found that only 20.2% of migrant and refugee women in six urban cities in Peru had access to modern contraceptives [56].Contraceptive access was reported to be influenced by family and relationship status as well as dynamics.For instance, among migrant and refugee women in six urban sites in Peru, lower socio-economic status was associated with reduced likelihood of emergency contraceptive use, and those who were married or lived with a partner were more likely to use modern and emergency contraceptives [56].A qualitative study with forcibly displaced women in West Bekaa, Lebanon described that beliefs about wanting a large family size were often in tension with the financial hardships they experienced in displacement, men held the dominant role in making decisions about family planning, and contraceptive access was hindered by the unaffordability of the privatised health system [43].Another qualitative study found that internally displaced women in Maputo, Mozambique experienced social isolation excluding them from the contraceptive revolution in their host community [31].Together these studies paint a complex picture of contraceptive access and needs, where some factors associated with low contraception uptake may include structural barriers (e.g., low socio-economic status), relational factors, (e.g., relationship status), and socio-cultural values and priorities (e.g., wishes for larger family sizes) shaped by community norms and experiences of conflict.

Grey literature findings
Among the 37 included grey literature reports, over three-quarters (n = 29) examined GBV ; these studies are detailed in Table 3. Emergent GBV themes centered on vulnerabilities to experiencing sexual, physical, and psychological abuse.Reports describe forcibly displaced in urban humanitarian contexts were at elevated risk for GBV exposure due to various social, cultural, and political dynamics, such as income insecurity, overcrowded living conditions, inequitable gender dynamics, inequitable power dynamics with administrative authorities, and limited awareness of rights [86, 88, 90-94, 97, 101, 104, 105, 108].Perpetrators of GBV included landlords, neighbors and employers, all of whom displaced people may be dependent on, and in lower positions of power [104,105].The main reported targets of violence were women, sexual minorities, and transgender people [83, 85-87, 94-96, 100, 107, 108].These reports, taken together, emphasize the importance of integrated policies, research, and SRH services to reduce GBV and promote health equity among individuals at risk, including sexually and gender diverse persons.Additionally, the reports emphasize the critical need for support services to aid GBV survivors [79,82,85,98,103].
Other themes identified from the grey literature include sex work, disability, contraception needs, and the needs of people living with HIV.Two reports addressed sex work among displaced people who may fear social and legal consequences (including stigma and prosecution) if their sex work was disclosed; accordingly, mobile clinics were suggested as an appropriate entry point for SRH services tailored for forcibly displaced sex workers [80,109].Another report described barriers to accessing SRH services, including HIV/STI testing and family planning, for forcibly displaced persons with disabilities, noting stigma faced by forcibly displaced people with disabilities [106].Multiple studies described SRH service gaps, notably a lack of choice regarding a variety of family planning methods for forcibly displaced women, and limited access to HIV care for forcibly displaced people living with HIV [113,115,116].Recommendations for improving access to SRH services for urban forcibly displaced people included: (1) improved collaboration between various systems and authorities that forcibly displaced people interface with; (2) wider dissemination of SRH knowledge to forcibly displaced persons; (3) the need to create safe, inclusive, and culturally-aware SRH spaces; and (4) the importance of empowering women and girls in humanitarian contexts to mitigate gender inequity as a barrier to SRH access [110][111][112]114].

Discussion
Findings from this scoping review underscore that forcibly displaced individuals in urban LMIC settings face multiple barriers to SRH.These barriers encompass structural (e.g., loss of livelihoods, lack of health insurance), social (e.g., limited access to community support), interpersonal (e.g., gender inequitable relationship dynamics), and intrapersonal (e.g., poor mental health) factors.These barriers align with a social ecological [117,118] approach to health that accounts for the complex interplay between different spheres of influence, and can inform tailored interventions that target one or more levels for change (see Fig. 2).Our findings also identify understudied sexual health (i.e., sexual function and psychosexual counseling) and reproductive health (i.e., fertility care, safe abortion care) domains with this population.
We found across included studies that displacement processes were discussed as exacerbating SRH vulnerabilities among forcibly displaced persons in urban LMIC settings [31,36,37,54,57,60,65,78].These included the role of displacement in the breakdown of social support networks and loss of livelihoods in increasing exposure to GBV while also reducing access to sexual health services such as HIV/STI testing.However, the paucity of studies precludes synthesizing experiences by SRH domain (e.g., safe abortion), setting (e.g., slums/informal settlement), or population (e.g., adolescent).A similar limitation was identified by Singh et al. in their 2018 systematic review on the utilization of SRH services in humanitarian crises at large [119].This observation signals a persistent lack of substantial progress in advancing the field as a whole, and in turn the contextually specific needs of urban forcibly displaced persons.We also found a limited focus on safe    abortion and STIs beyond HIV.This suggests a need for additional attention to these understudied SRH issues.
Our findings indicate that stigma experienced by urban forcibly displaced persons presents barriers to SRH prevention, access, and care.Stigma is intersectional, targeting various identities such as refugee status and gender and spans across social-ecological levels, including being manifested at structural (e.g., laws and policies), health institution (e.g., healthcare mistreatment), community (e.g., stigma toward refugees), interpersonal (e.g.genderbased stigma), and intrapersonal (e.g., self-stigma) levels.Moreover, stigma is rooted in drivers and facilitators that could be effectively addressed through targeted stigmareduction interventions [120].Stigma within healthcare facilities can reinforce a wider mistrust of health systems among refugee and displaced persons [17,51].There is scarcity of SRH interventions focused on stigma reduction with this population.
We documented that resource scarcities (e.g., food, housing, economic) were associated with worse SRH outcomes among urban forcibly displaced persons [37,60,75,76].This reflects the long-standing insufficient funding and resources for SRH (and health care more generally) in humanitarian settings [48].Once a forcibly displaced person leaves a formal refugee settlement/ camp to migrate to urban regions, many forgo formal financial support offered by UNHCR or other refugee settlement-based organizations to refugees living in settlements, such as food, land/housing, or economic stipends.They may then experience financial challenges, such as transportation costs to accessing healthcare, high rent in cities and/or substandard housing in urban informal settlements, in addition to lack of health insurance in some contexts.These resource scarcity barriers to SRH care are further exacerbated by individual-level barriers such as low literacy and language barriers, and systemiclevel barriers such as insufficient staffing and medication stock-outs.
Our study has limitations.We focused on a select range of SRH outcomes as defined by a SRH conceptual framework [28,29] and may have overlooked other important issues relevant to SRH outside of this (e.g., fistulae).Our Fig. 2 Conceptual framework of multi-level sexual and reproductive health care barriers and challenges among urban forcibly displaced persons in low and middle-income countries criteria for language inclusion may have omitted some relevant articles.As there was so many different contexts, article types, refugee types (e.g., displaced, refugee), and populations (e.g., adolescents, pregnant adult women), we could not conduct a meta-analysis, and even when synthesizing key findings this heterogeneity presented challenges in contextualizing SRH findings within each setting and its socio-cultural norms, geography, country income, and laws and other social determinants of health.It is plausible that urban refugees may share health status outcomes with host communities while living in urban informal settlements or slums due to the nature of shared socio-cultural and economic conditions in slums [121], yet these similarities and/or differences in SRH outcomes with host communities were beyond the scope of this review.Further, the studies included in our analysis exhibited a significant underrepresentation of large global regions, namely Africa, Latin America, and the Caribbean.This limited inclusion of studies from these regions hampers our understanding of the specific needs and priorities of urban forcibly displaced persons residing in these urban contexts (Figs. 3 and 4).Despite these limitations, this review's strengths include its unique focus on urban forcibly displaced persons in LMIC contexts, where the majority of forcibly displaced persons live.Our review also reinforces the need to include multiply marginalized communities in future SRH research-including urban forcibly displaced sex workers, people who use drugs, and lesbian, gay, bisexual, and transgender persons [122][123][124].
Urgent research and interventions are needed to address SRH challenges faced by urban forcibly displaced persons; these strategies can ultimately advance health equity and well-being not only for forcibly displaced persons, but in the case of those living in slums, interventions may have multiplier effects [121].Future research can identify targets for stigma reduction (e.g., healthcare workers, refugee women) and implement evidence-based intersectional stigma reduction strategies to mitigate barriers to accessing SRH care [125].Effectively advancing SRH in humanitarian settings requires resources for implementing and evaluating multi-level interventions integrated within existing health systems, as well as community-level, familylevel, and individual-level approaches.Such interventions can specifically address health literacy and language needs of urban forcibly displaced persons, transportation-related challenges (e.g., via mobile clinics), and, when needed, extend health insurance coverage to forcibly displaced individuals.Additionally, innovative approaches such as self-care strategies for SRH (e.g., HIV self-testing, long-acting self-injectable contraception, over-the-counter oral contraception, abortion self-management) hold significant promise in addressing some of these aforementioned SRH barriers and can be explored and tested with urban forcibly displaced persons.These self-care strategies may help to overcome challenges related to privacy, transportation, and healthcare provider mistrust [48,126], yet they also require an enabling social and health environment, so can be offered in tandem with strategies focused on advancing social and health equity [126].

Conclusion
This review identified barriers to SRH care spanning social-ecological levels [117,118] among urban forcibly displaced persons in LMIC contexts.The process of displacement, resource insecurity, and stigma exacerbate and drive SRH vulnerabilities for urban forcibly displaced persons in LMIC contexts.However, there remain critical knowledge gaps regarding a range of SRH issues across diverse LMIC settings, with particular knowledge gaps regarding socially marginalized populations.Our findings signal that in urban LMIC settings, there may be unique barriers to accessing SRH information, resources and care faced by forcibly displaced persons (e.g., no financial support from UNHCR or other refugee agencies, social isolation, language barriers at clinics) compared to formal refugee settlements where persons may have more access to refugee communities, translators at clinics, and financial stipends (e.g., housing, land, food supplements).Future research and action are required to address the unique and often unmet SRH needs among urban forcibly displaced persons to advance health and rights.

Fig. 1
Fig. 1 PRISMA flow diagram of a scoping review on urban forcibly displaced persons' sexual and reproductive health in low and middle-income countries

Quantitative N = 349
, pregnant refugee women SGBV/IPV To examine the correlates of forced sexual intercourse among pregnant refugee women attending an antenatal clinic Korri et al. (2021) [18] Bourj Hammoud, Lebanon Qualitative N = 40, adolescent Syrian refugee girls SRH literacy To understand sexual and reproductive health perceptions and experiences among adolescent refugee girls in an urban setting Krause et al. (2015) Zaatri Camp and Irbid City, Jordan Qualitative N = 170, Syrian refugee women and key informants Antenatal care, family planning, HIV, postnatal care, SGBV/IPV, SRH literacy, STIs To determine the status of Minimum Initial Services Package (MISP) implementation for Syrian refugees in Jordan as part of a global evaluation of reproductive health in crises Logie et al. (2019) (a) [47] Kampala, Uganda Quantitative N = 333, displaced adolescent girls SGBV/IPV To examine the prevalence of young adulthood violence (YAV) and recent IPV among refugee and displaced adolescent girls, and the social factors associated at an intrapersonal, interpersonal, and community level Logie et al. (2019) (b) [48] Kampala, Uganda Quantitative N = 445, refugee and displaced adolescents HIV To assess the reliability of the SRH stigma scale while examining the gender differences in both HIV testing uptake and HIV service awareness and their association with stigma among urban and refugee youth living in Kampala'prevalence of STI testing awareness, uptake, and diagnosis their impacting factors among urban refugee and displaced youth living in Kampala's informal settlements Logie et al. (2021) (a) [13] Kampala, Uganda Quantitative N = 412, refugee and displaced adolescents HIV To examine the relationships between HIV prevention and transactional sex among urban refugee and displaced youth in Kampala Logie et al. (2021) (b) [50] Kampala, Uganda Qualitative N = 44, refugee and displaced adolescents HIV To understand HIV testing experiences among urban refugee youth in Kampala, and their perspectives on HIV self-testing Logie et al. (2021) (c) [51] Kampala, Uganda Qualitative N = 44, refugee and displaced adolescents HIV To explore the experiences, preferences and engagement with HIV testing and prevention among urban refugee adolescents and youth in Kampala, Uganda, with a focus on the role of contextual factors in shaping access and uptake Logie et al. (2022) (a) [24] Kampala, Uganda Qualitative N = 44, refugee and displaced adolescents HIV To examine contextual factors that impact HIV testing and prevention based on the experiences of urban refugee and displaced adolescents and youth in Kampala Logie et al. (2022) (b) [52] Kampala, Uganda Quantitative N = 445, refugee adolescents HIV, SGBV/IPV To understand the interactions between frequent alcohol use, depression, and violence on HIV vulnerability among urban refugee youth Logie et al. (2022) (c) [53] Kampala, Uganda Quantitative N = 450, refugee adolescents HIV To examine the association of HIV testing and social contextual factors among urban refugee youth López et al. (2010) [54] Medellin, Colombia Qualitative N = 23, forcibly displaced women HIV, STIs To determine the social vulnerability to sexually transmitted diseases and AIDS in women forcibly displaced in Medellin Malama et al. (2023) [55] Kampala, Uganda Quantitative N = 333, refugee and displaced adolescent girls Family planning To determine the factors associated with motherhood among urban refugee adolescent girls and young women

Fig. 3
Fig. 3 Map of countries of included peer-reviewed studies in this scoping review of urban forcibly displaced persons' sexual and reproductive health in low and middle-income countries.Included countries are represented with colours reflecting the number of studies from each country reported in the figure legend

Fig. 4
Fig. 4 Map of countries of included grey literature studies in this scoping review of urban forcibly displaced persons' sexual and reproductive health in low and middle-income countries.Included countries are represented with colours reflecting the number of studies from each country reported in the figure legend

Table 1
Overview of peer-reviewed articles (n = 55) included in scoping review on sexual and reproductive health of urban forcibly displaced persons in low and middle-income

Table 3
Overview of grey literature articles (n = 37) included in scoping review on sexual and reproductive health of urban forcibly displaced persons in low and middle-income countries